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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE:PROGRAM SURVEY FORM Facility Name: d� ® IvQ Page _of� Facility Addr s: City: Inspects n D e: z � �/z ra �f 3 07 FA#: OR#: Program771,T)en • Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers". Complete one box for each tank or each cumulative container product type. #of Containers: Ti ank (2820) El Containers (2821) ners: ' 1Product Type: Total Capacity: � d gallons •— -- -- (per tank or cumulative for containers by product type), Install Date: LK Tank (2820) ElContainers (2821) #of Containers; TA 2 Total Capacity: gallons Product Type: � - (per tank or cumulative for containers byproduct type) - Install Date: �nk (2820) ❑ Containers (28 2.1) #of Containers: TA#: 3 Total Capacity; Product Type: `' L, b 8 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Ca acit Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: ❑ 'Tank (2820) ElContainers (2821) #af Containers: TA#: 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: d gallons Total Capacity for Site: S gallons Comments: EHD Inspector: Reviewed ` . � Date: Entered Date ✓ sy Initial: k1-"' l,i-�t{�0�1 By Initial: I� *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. "Container means a storage device designed to be moved when full EHD 28-01 AST SURVEY FORM 09!12!08 I